Step 1 of 10 10% Applicant InformationLegal Name of Company* Effective Date of Coverage* Mailing Address* City* State* Zip Code* Email Address* Years in Business Inspection Contact Inspection Phone Federal ID# Type of Business Individual Corporation LLC Partnership Joint Venture Other (describe) Towing# of Employees Payroll Receipts Service Station# of Employees Payroll Receipts Auto Mechanic# of Employees Payroll Receipts Auto Body Shop# of Employees Payroll Receipts Used Car Sales# of Employees Payroll Receipts Repossession# of Employees Payroll Receipts TruckingIf Trucking Section Completed, Need Receipts# of Employees Payroll Receipts Other# of Employees - other Payroll - other Receipts - other Description of Other OperationsFive Largest Clients For Which The Applicant Tows (including police, commercial and auto clubs)Client 1 % of Business Client 2 % of Business Client 3 % of Business Client 4 % of Business Client 5 % of Business Is the Applicant involved in any repossession? Yes No If yes, are the repossessions: voluntary? involuntary? How many repossessions are performed each month? Is the Applicant involved in anything other than towing? Yes No (If yes, please complete the Operation Section)Is applicant subsidiary of another entity or does applicant have any subsidiaries? Yes No If yes, name and describe: Is there a formal safety program in operation? Yes No If yes, number of meetings held monthly Who conducts? (Include a copy of written safety program if one exists)Is there a written vehicle maintenance program in operation? Yes No Any vehicles leased, loaned or rented to others? Yes No If yes, describe: Are these vehicles included in the attached schedule? Yes No If no, explain why: Describe customized or special equipment OTHER THAN tow equipmentAny ICC filings required? Yes No Any PUC filings? Yes No If yes, list below:NameAddressIf yes, does Applicant comply with all record keeping required by D.O.T.? Yes No Is MCS 90 Required? Yes No Authority is granted in the name of: How many times monthly does the Applicant go beyond 50 miles? How many times monthly does the Applicant go beyond 200 miles? What cities? Does the Applicant carry Workers Compensation? Yes No Policy Period Insurance co. What is the total number of vehicles the Applicant owns? Does the Applicant pick up or deliver customer’s cars other than Towing? Yes No If yes, what radius of operation? Any Tire Sales? Yes No If yes, receipts How does the Applicant dispose of used tires? Does the Applicant sell: New Tires Used Tires Any tire recapping or retreading performed? Yes No Does the Applicant own or sponsor a car for racing? Yes No Any spray painting performed? Yes No If yes, does Applicant have an UL approval spray booth? Yes No Any welding performed? Yes No If yes, where is welding performed? Any protective screens used? Yes No Untitled First Choice Second Choice Third Choice Does the Applicant operate a service station? Yes No Type of service station is: Self-Station Full-Service Both Does the Applicant operate: C-Store Car Wash Gallons sold annually How many pumps does the Applicant have? Does the Applicant have a pollution liability policy on the underground storage tanks? Yes No Does the Applicant do any dismantling or salvage? Yes No If yes, how many number of units annually? Does the Applicant own a crushing machine? Yes No If yes, describe here: Is public allowed to removed parts from vehicles? Yes No Is public allowed access to the salvage area? Yes No Do employees regularly use their own vehicles on company business? Yes No If yes, explain Does the Applicant have any public parking for which charge is made? Yes No If yes, number of units per month Monthly Receipts $ Does Applicant have dogs on Premises? Yes No If yes, number If yes, breed Are they Police/security trained Guard Dogs? Yes No Are “Beware of Dog” signs posted on gate? Yes No Are dogs penned up during business hours? Yes No Location 1Fenced (Y/N)HeightGates Locked at Night (Y/N)Watchman (Y/N)Alarm (Y/N)Avg. # of CarsLocation 2Fenced (Y/N)HeightGates Locked at Night (Y/N)Watchman (Y/N)Alarm (Y/N)Avg. # of CarsLocation 3Fenced (Y/N)HeightGates Locked at Night (Y/N)Watchman (Y/N)Alarm (Y/N)Avg. # of CarsLocation 4Fenced (Y/N)HeightGates Locked at Night (Y/N)Watchman (Y/N)Alarm (Y/N)Avg. # of CarsLocation 5Fenced (Y/N)HeightGates Locked at Night (Y/N)Watchman (Y/N)Alarm (Y/N)Avg. # of CarsDays of operation Mon Tues Wed Thurs Fri Sat Sun Normal hours of operation 0-12 hours 13-17 hours 18-24 hours If storing cars, for whom and under what circumstances are autos stored by the Applicant? Any change in operation, number of vehicles in the last 3 years? Yes No If yes, please explain Attach copy of insurance company loss runsMax. file size: 100 MB.Has Applicant ever been cancelled or non-renewed? Yes No (Do not answer if risk is located in MO)If yes, why? Driver Information:Does the Applicant require written application? Yes No Does the Applicant check reference? Yes No Does the Applicant check driving records? Yes No Does the Applicant check driving records? Yes No List any Towing Schools attended How are Drivers paid? Hourly Weekly Commission Salary Does the Applicant have a safe driving incentive program? Yes No If yes, explain: Are the Drivers the Applicant’s employees? Yes No If no, name of contractor Does the Applicant use owner operators? Yes No Has the Applicant hauled anything other than vehicles within the past 3 years, (including incidental hauls)? Yes No If so, please complete the SECTION below.Items(s) HauledValueRadiusVehicle UsedHow OftenItems(s) HauledValueRadiusVehicle UsedHow OftenItems(s) HauledValueRadiusVehicle UsedHow OftenItems(s) HauledValueRadiusVehicle UsedHow OftenWhich Drivers handle these operations? Does the Applicant use air bags in its towing and recovery operations? Yes No If yes, how many bags? If coverage for equipment is desired, please attach list of equipment with I.D.#s and values.Does the Applicant always use safety chains? Yes No Does the Applicant, at any time, perform snow plowing? Yes No If yes, who does the Applicant plow for? Vehicle ScheduleInsured Name: Date: Upload Vehicle and Driver List Drop files here or Select files Max. file size: 100 MB. Or manually fill out belowVehicle #1YearMakeModelBody TypeVIN#Stated AmountGVWClass CodeOn-Hook LimitDeductibles: CompDeductibles: CollisionDeductibles: On-HookUse of vehicleRadius of operationDescribe tow/specialty equipment separately (rotator, etc.)Garaging LocationVehicle #2YearMakeModelBody TypeVIN#Stated AmountGVWClass CodeOn-Hook LimitDeductibles: CompDeductibles: CollisionDeductibles: On-HookUse of vehicleRadius of operationDescribe tow/specialty equipment separately (rotator, etc.)Garaging LocationVehicle #3YearMakeModelBody TypeVIN#Stated AmountGVWClass CodeOn-Hook LimitDeductibles: CompDeductibles: CollisionDeductibles: On-HookUse of vehicleRadius of operationDescribe tow/specialty equipment separately (rotator, etc.)Garaging LocationVehicle #4YearMakeModelBody TypeVIN#Stated AmountGVWClass CodeOn-Hook LimitDeductibles: CompDeductibles: CollisionDeductibles: On-HookUse of vehicleRadius of operationDescribe tow/specialty equipment separately (rotator, etc.)Garaging LocationVehicle #5YearMakeModelBody TypeVIN#Stated AmountGVWClass CodeOn-Hook LimitDeductibles: CompDeductibles: CollisionDeductibles: On-HookUse of vehicleRadius of operationDescribe tow/specialty equipment separately (rotator, etc.)Garaging LocationVehicle #6YearMakeModelBody TypeVIN#Stated AmountGVWClass CodeOn-Hook LimitDeductibles: CompDeductibles: CollisionDeductibles: On-HookUse of vehicleRadius of operationDescribe tow/specialty equipment separately (rotator, etc.)Garaging Location Driver ListDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceHave you identified every possible driver of an insured vehicle including those who may fill in during peak periods and emergencies? (Such as members of households, friends, etc.)? Yes No Name of Applicant , understands and agrees that on any proposed addition or substitution of driver, the MVR must be submitted to the insurance company for approval prior to hire. Δ
